Remembering an influential article.
Patricia Speck
Timing is everything. Forensic nursing service through telehealth is possible today, as reported in a recent Kaiser Health News story, but it wasn’t always that way. Fifty years ago, Ann W. Burgess, a psychiatric–mental health nurse working in the emergency room, wrote a paper with a sociologist colleague about what she was seeing in patients who complained of being raped. “The Rape Victim in the Emergency Ward” (pdf), published in AJN, was reported nationally and informed 1970s kitchen table conversations about what rape is, is not, and when “no means no.”
Naming the trauma and its effects.
The ideas in this article were new at the time. Burgess wrote that sexual assault causes acute emotional trauma, requiring time for recovery, and she named phases of what she eventually called “rape trauma syndrome.” Prior to the article, victims of sexual assault often did not report the assault, and when they did they waited hours for a newly minted physician intern who had been punished with “rape-duty.” These physicians had no knowledge about what to do.
In accordance with societal views at the time, victims were often blamed for their rape—the way you dress, how you act, if you were drinking. Even if you were bloodied and bruised, society assumed that if you were raped, you had “asked for it.”
Beverly H. Bowns, a nurse practitioner faculty at the University of Tennessee Health Science Center, is likely to have read the article and known we can do better. She wrote a grant, received federal funds, and brought stakeholders together to train the first three nurse practitioners to be on call to respond to police and to meet assault victims at a newly established Title X family planning clinic. The three NPs were trained by forensic scientists to collect evidence using the Vitullo Kit and provide medical prophylaxis for disease and pregnancy in a compassionate way to the traumatized woman.
That was 1973. The new role was immediately very successful, as evidenced by increasing reports, but it would be almost 20 years before nurses doing this work were given the name of forensic nurses.
Making forensic nursing a specialty.
In 1995, the ANA designated the role of the forensic nurse a specialty, covering a number of subspecialty practices such as psychiatric-mental health, emergency, death investigation, child and elder maltreatment, and violence against women, both sexual and domestic. In 1996, the term sexual assault nurse examiner or SANE was adopted by the forensic nurse subspecialty special interest group and the ‘sexual assault nurse clinician’ became an ‘examiner.’
In the early days, patients would travel hours for the services of a forensic nurse caring for crime victims and the accused. Victims in rural communities were often sent into the night to a regional program in an unfamiliar city several hours away. Is it any wonder that they would turn around and go home?
The role grew and so did the number of graduate programs that offered specialty tracks in forensic nursing. These were the forensic nurse leaders in the 1990s and early 2000s. Nurses in subspecialties such as SANEs received training through continuing education coursework. However, sustaining the RN in the role was more difficult. Many suffered significant provider fatigue and burnout. Hospitals didn’t see financial benefit in having a program either, and many SANE programs folded.
Growing awareness and recognition of sexual crimes has gradually increased the demand for forensic nurses with sexual assault training. Other populations, such as victims of sex trafficking, have benefited as the number of SANEs increased. Policy makers changed child sexual abuse and minor sex trafficking reporting through Title X family clinics, legislators began to use the term forensic nurse in grants, and academic institutions were adopting Forensic Nursing Certification Board core competencies that defined content for all undergraduate and graduate forensic nurse programs of study.
A role for telehealth, and continuing limitations.
By 2012, the Department of Justice was meeting to consider funding for telehealth by forensic nurses. During the COVID-19 pandemic, telehealth was rapidly accepted by the medical community. Nursing compact states had also increased in number, enabling many nurses to cross state lines as traveling nurses.
Unfortunately, timing is everything and compact status is not enjoyed by advanced practice nurses. Because of this, the use of telehealth is limited in states that are not part of the nursing compact. Regardless of compact status, sexual assault evaluation using telehealth may be synchronous or asynchronous, may be a telephone consult or use technology that transmits encrypted protected health information. With the compact states now allowing RNs to practice in other compact states, SANE RN practice challenges will come. All states distinguish between RN and advanced practice using a license from the state’s board of nursing. The APN license is based on education foundations of the three P’s—physiology, pharmacology, and health assessment (focused on creation of a differential diagnosis).
Confounding the problem is continuing education training that encourages RNs to offer an ‘opinion’ as to cause of injury when asked about ‘medical certainty,’ which is a legal term. RNs do not have licensed authority to offer a differential diagnosis or predict medical certainty without extensive knowledge of the literature. What RNs do best is assess the patient, document, describe, quote, recognize and refer potential medical sequelae, all by following protocols.
Telehealth is a new layer of complexity, and advanced practice nurse leaders who are certified advanced forensic nurses supervising RN SANE practices must become proactive in protecting the RN using new technology with protocols that highlight what the RN SANE does best. These programs offer comprehensive services, including access to experienced forensic nurses and on occasion to certified advanced forensic nurses with graduate preparation.
The advantage of having bedside RNs trained as SANEs is the best hope for increasing access to care following sexual assaults and rapes. Systems continue to evolve and risks to RN SANE practice are continually present. But with remote assessments, the basic premise remains the same. When a person experiences sexual assault, there needs to be a local provider with protocols and technological access to an experienced forensic nurse with specialized training in the care of the sexual assault victim. The future of such practice will depend on a well-developed system of certified and advanced forensic nurse providers. Timing is everything.
Patricia Speck, DNSc, CRNP, FNP-BC, AFN-C, DF-IAFN, FAAFS, DF-AFN, FAAN, is a professor and coordinator of advanced forensic nursing in the Department of Family, Community, and Health Systems at the University of Alabama at Birmingham School of Nursing.
Thank you for your comment. Unfortunately, financial decisions are often made without stakeholder input, aptly described in your response. Ideally, a forensic nurse with skills to care for the sexually victimized population is in every community. Until then, evidence supporting telehealth is an improvement to no care, particularly helpful in many underserved areas of medical care delivery, even in the same urban area or in a compact state miles away. For forensic nurses who are graduate students reading this comment, consider quality improvement strategies in your quality improvement projects to minimize the concern about a negative impact due to administrative changes, described in the comment. These projects will look at patient response before and after telehealth, with and without a forensic nurse, forensic evidence accuracy and usefulness, and informatics issues related to confidentiality, among others. Data from the patient and the community systems that serve the person who experienced sexual violence are necessary to inform organization administrations and improve care everywhere, where graduate schools and their nursing programs of study teach forensic nurses how to improve access, quality, and safety of care. Thank you for your comment and commitment to patients experiencing sexual violence. Dr. Speck
Our regional hospital has just canceled the contracts for onsite SANE (adult and pediatric) nurses in favor of so-called telehealth services, in which an ER nurse does the rape kit guided telephonically by an actual SANE nurse offsite. This appalling development raises questions about competence, confidentiality, chain of custody, and later testimony, of course. It’s also a horrible way to treat a victim of sexual assault, to say the least. An outpouring of public outrage from many quarters, including women’s advocacy and support groups and nurses, failed to get this reversed.